Ready for Action
A new dynamic brace for correcting clubfoot lets kids be kids.
"I explain to parents that clubfoot correction is 2 percent in our hands and 98 percent in theirs."
When Nathan and Sarah Page got an ultrasound during her second pregnancy, they saw that their little boy would be born with clubfoot. "I was very upset," Sarah Page says. "As the mom, you think 'This baby isn't even here yet and there is already something wrong.' It was terrifying."
Nathan Page, a fourth-year resident at Barnes-Jewish Hospital, asked his colleagues which doctor they needed to see, and everyone recommended Matthew B. Dobbs, MD, associate professor of orthopaedic surgery and an orthopaedic surgeon at St. Louis Children's Hospital.
"Once we saw Dr. Dobbs and realized that treatment wouldn't require major reconstructive surgery, we were relieved," Sarah Page says.
Until recently, the most innovative, nonsurgical treatment for clubfoot was developed in the 1950s. The treatment, developed by Dobbs' mentor at the University of Iowa, Ignacio Ponseti, MD, involves weekly casting and manipulation of the clubfoot starting soon after birth. Then, the children wear a fixed-bar brace at night until about age 4 to maintain the correction of the foot. But that brace restricts the child's movement and has the potential to cause skin blistering, which led many parents away from using the brace as prescribed. Using the brace less than prescribed can lead to recurrent clubfoot deformities, which may eventually require extensive surgery.
Intent on making the brace easier to tolerate for both patients and families, Dobbs designed a new dynamic brace to allow active movement, preserve muscle strength in the foot and ankle and be less restrictive to the child than the traditional version. The new brace, patented as the Dobbs brace, has shown significantly improved compliance and fewer complications than the traditional brace. In a two- to three-year follow-up study of patients treated for clubfoot at St. Louis Children's and St. Louis Shriners hospitals, 95 percent of parents used the Dobbs brace as prescribed on their children, compared to 60 percent compliance when parents used the traditional brace.
Clubfoot is a congenital birth defect that occurs in about one in every 1,000 live births and affects boys twice as often as girls. About half of clubfoot cases affect both feet, including the bones, muscles, tendons and blood vessels. If untreated, those affected walk on the outside of their feet, a part of the physiology not designed to bear weight.
The Dobbs brace has a soft, custom-molded insert that is placed inside of a solid ankle-foot orthosis, an orthopedic appliance designed to maintain alignment of the bones in the foot and ankle. The lighter-weight bar connecting the feet has a release mechanism that allows parents to easily detach and reattach the bar to place the child in a car seat or high chair or change a diaper without removing the entire brace, and hinges at each end so the feet can easily pivot. In addition, children wearing the brace can walk, crawl and move their legs independently — things that were difficult or impossible wearing the traditional brace. It secures to the ankle-foot orthosis using Velcro straps instead of buckles or laces used on the traditional brace.
Dobbs says these design changes are key to preventing a recurrence of clubfoot.
"While we've had good success in obtaining correction in clubfeet, maintaining that correction has been more challenging," he says. "If the kids are happier and are tolerating the brace well, then they have happier parents, which leads to improved compliance."
Sarah Page says their 18-month-old son, Jimmy, has used the Dobbs brace since he was 3 months old. "We decided to use the Dobbs brace after Jimmy's casting treatment, and we never questioned it," she says. "Jimmy has been fine with it, and now he helps us when we put the brace on him and is very possessive of his shoes. It hasn't limited what he can do."
The Page family lovingly refers to Jimmy's Dobbs brace as "Jimmy's Choos," a play on fashion shoe designer Jimmy Choo.
Sarah Page says when they met with Dobbs before Jimmy's birth, he told them that most of the treatment depended on the Pages.
"I explain to parents that clubfoot correction is 2 percent in our hands and 98 percent in theirs," Dobbs says. "Our casting work takes about two months, but the parents are bracing the feet for three to four years. If they don't put the brace on the child, the clubfoot will recur."
Some parents of patients with clubfoot whom Dobbs treats still want a quick fix with surgery, he says. "It seems like a quick fix, but what parents don't realize is that 20 years later, their child's foot will likely get stiffer and develop painful arthritis."
All 28 patients in Dobbs' study, published in the Journal of Pediatric Orthopaedics, had worn casts for their clubfoot before being fitted for the brace. Eighteen patients who had not been wearing the traditional brace as prescribed were fitted for the Dobbs brace. The remaining patients were fitted only for the Dobbs brace. All but two patients wore the brace as prescribed.
Of the two patients who were noncompliant in wearing the brace, one patient had skin blistering due to improper use of the brace, which was eventually corrected, while the other patient was not kept in the brace because of the caregiver's work schedule.
Dobbs says the bar connecting the feet eventually will be available independently and can be used with other types of corrective footwear for clubfoot. "Just having the flexible bar makes a huge difference in compliance and convenience," he says.
"The newly designed, more flexible foot abduction orthosis is equally effective, or more so, than the traditional brace, considering rates of clubfoot relapse were less with the new orthosis than those reported in several series using the traditional brace," Dobbs says. "Although our experience with the dynamic brace has been favorable, a randomized study comparing the dynamic orthosis to the traditional brace would provide a more accurate assessment of outcome."